Provider Demographics
NPI:1902832405
Name:COASTAL SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:COASTAL SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-332-6774
Mailing Address - Street 1:4147 SOUTHPOINT DR E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-0996
Mailing Address - Country:US
Mailing Address - Phone:904-332-6774
Mailing Address - Fax:904-332-9137
Practice Address - Street 1:4147 SOUTHPOINT DR E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-0996
Practice Address - Country:US
Practice Address - Phone:904-332-6774
Practice Address - Fax:904-332-9137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14960580261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6N6OtherBCBS
FLF1464Medicare ID - Type UnspecifiedASC